P - 84695� REQUEST FOR ELECTRICAL INSPECTION -°�.
- 4 8 2° 9 01 Minnesota State Board of Electricity
1821 Universiry Ave., Rm. S-128, St. Paul, MN 55104
Phone (612) 642-0800
Home Duplex Apt. Bidg. Oiher: New Addn
Commercial Indusfrial Farm Remod Re ir
Air Cond. Htg. Equip. Water Hh. Load Mgmt. Other:
Dryer Range Elec. Heat Temp. Service
"X" above the ork cover� by lhis �equest. Enter r m ks in this space and on the back of the whiie copy only.
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Calculate Inspection Fee - This Inspection Request will not be accepted without the correct fee:
Other Fee # Service Entrance Size Fee # Circuits/Feeders Fee
Mobile Home Park Stall 0 to 200 Amps 0 to 100 Amps
Street Ltg./Traffic Sig. Above 200 Am s Above 100 Amps
Transformer/Generator INSPECTOR'S USE ONLY TOTA �'1'/
Sign/Oudine Ltg. Xfmr. Q;.
L1r'
Alarm/Remote Conhol
Swimming Pool
I hereb certi Ihat I ins fed ihe electrical installaHon dexribed herein on the dofes sfated
Irrigafion Boom RouyMn Dare
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Investigative Fee - - _ --Z� ` � � ""
THIS INSTALLATION MAY BE ORDERED DISCONNECTED IF NOT COMPLETED WITHIN 18 IIrO HS.
OFF7CE USE ONLY This requesf void 18 monlhs from validation date printed in this box.
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* � 4 8 2 9 � L 6�K PLEASE PRINT OR TYPE
2equesf Date Rou h-in ins ion r uired? Yes
g pecl' eq � ❑ No Inspecfion Other Than RougMn: ❑ Ready Now,�Will Call
/Q���� �You musf call the inspecior when ready) Date Ready:
I, �licensed contractor ❑ owner hereby rsquest inspection of the above electrical work at:
lob Address �Streef, Box, or RouM No.� Cily _
No. � Township Name or N�- � Ranqe No. � Fire No.
Phone No.
(Company Name) /�� Conhactor License No.
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Mailing Address (Corihactor or
STA COPY - SEE INSTRUCiIONS ON BACK OF YELLOW COPY
No.